Monthly Archives: November 2015

“Now, the boys and girls up in marketing all know that advertisements and commercials don’t sell products. Advertisements and commercials sell what? Sex and gender! That’s right! And sex and gender sell what? The products? Very good! Sex, because it’s sex. And once you’ve had great sex, well, you’re going to want some more. And if you’ve never had great sex, you’ll buy anything hoping to get some. But gender—that’s another can of worms. That’s a different kettle of fish. That’s another pea in a different pod. Simply put, once you buy gender, you’ll buy anything in order to keep it. You’ll buy anything. So—the boys and girls up in marketing have come up with the ultimate marketing strategy. We’re not going to sell you any products tonight, no we’re going to sell you gender. And you want to buy it.

You want to buy gender because you want to relieve the nagging feeling that you’re not quite a man, not quite a woman.”

Doc Grinder speaking in the play Hidden: a Gender by Kate Bornstein, from Gender Outlaw, page 173.

If you or someone you know is struggling with an eating disorder, we are here to help.

Call our toll free, confidential Helpline at 1-800-931-2237

Click to chat with a Helpline volunteer (click at left on their website)

We are here every Monday-Thursday from 9:00 am – 9:00 pm and Friday from 9:00 am – 5:00 pm (EST). Our helpline volunteers will be there to offer support and guidance with compassion and understanding.”

“The Central City Anti-Poverty Program Office opened that fall as a result of the Tenderloin neighborhood organizing campaign. This multiservice agency included an office for the police community-relations officer to the homophile community, a police sergeant by the name of Elliott Blackstone. One afternoon shortly after the agency opened, a transgender neighborhood resident named Louise Ergestrasse came into Blackstone’s office, threw a copy of Benjamin’s The Transsexual Phenomenon on his desk, and demanded that Blackstone do something for ‘her people.’ Blackstone was willing to be educated on the matter, and he soon took a leading role in changing police treatment of transgender people.”

This is a case study of a trans man (born female) with many serious mental health problems, including an eating disorder. He was a survivor of childhood sexual abuse and the trauma seems to have been at the root of his problems.

This case study does not make any connections between his eating disorder and his gender dypshoria. Given the abuse and the multiple comorbidities, it is unlikely that the gender dysphoria caused the eating disorders.

The authors suggest that both the eating disorder and the gender dysphoria were caused by the early trauma.

“the underlying foundation of these multiple diagnoses is the presence of early developmental trauma to the emotion regulation system — which manifests as physical and emotional pain with impulsive and maladaptive attempts to engage in behaviors to meet personal needs, including safety. Zanarini and colleagues performed a study examining Axis I comorbidity in patients with BPD [borderline personality disorder] and identified high rates of comorbid PTSD. They also observed that meeting criteria for multiple Axis I disorders predicted meeting criteria for BPD.”

Medical transition came later and was not part of the recovery from the eating disorder. However, at the time the patient entered therapy, he had already taken a male name and was dressing and living as a male.

This case study has some similarities to the case of a teenage girl* who developed gender dysphoria while being treated for an eating disorder. The teenage girl was also a survivor of childhood sexual abuse with multiple mental health problems: anxiety, depression, an eating disorder, excessive exercise, and OCD-type rituals related to germs (spraying her body with Lysol and excessive hand-washing). In addition, she had a past history of PTSD, OCD, self-harm, and suicidal thoughts.

These two cases suggest that in some cases, gender dysphoria is not the main cause of an eating disorder. Rather, trauma causes multiple mental health issues.

There are two more case studies of transgender people with eating disorders who were survivors of child abuse. They suggest different possible conclusions, however.

A trans woman whose eating disorder began when she started to live as a woman. Her goal was to have a more feminine shape. Transition and hormones did not cure the eating disorder, however. She had been physically and sexually abused as a child.

A trans woman whose identical twin also had an eating disorder. Both twins were feminine in behavior from a young age and both were sexually attracted to men. Both survived an abusive father who threatened them with assault and death. However, one was a trans woman and one was a gay man.

In the first case, the eating disorder seems to be closely connected to the gender dysphoria since it started when she began to live as a woman. She clearly describes wanting to look more female. The abuse may have affected her, but gender dysphoria was also a factor.

In the second case, the eating disorder seems to have been caused by a combination of genes and environment, since both twins had anorexia but only one had gender dysphoria.

We’re left with the possibility that the answer is different in different cases. Sometimes severe childhood trauma may cause multiple mental health problems that include an eating disorder. Sometimes a combination of gender dysphoria and early childhood trauma may contribute to an eating disorder. And sometimes the same genes and environment will produce two people with similar eating disorders but different gender identities.

Of course, these are only four case studies. We can’t draw conclusions from them about all transgender people with eating disorders. Most of the case histories I have found don’t mention child abuse. Many of them suggest connections between gender dysphoria and eating disorders.

What we can see from these cases, however, is that for some transgender people with eating disorders, gender dysphoria is not the main or only cause of their eating disorder. Therapists should keep this in mind when treating transgender patients for eating disorders.

The article provides an interesting discussion of diagnosing and treating a patient. The full text is available online without cost, but here are a few details of the case:

The trauma the trans man survived involved “repeated episodes of sexual violence perpetrated from age 4 to 9 years old by a childhood friend’s father in the neighborhood.”

…

“The patient believed he had suffered multiple head injuries related to physical violence and asphyxiation in the context of sexual trauma, but was unclear if he had lost consciousness because of head injury or because of psychological dissociation during these events.”

…

He had “a history of heavy chemical use, starting with first use of alcohol at age 7, which continued through age 23. He also used diet pills starting at age 14, followed by heavy use of cannabis at age 15, and cocaine and other narcotics, including pills and heroin, at age 18 years.”

…

The patient had severe pelvic floor dysfunction which caused him a great deal of pain. It took him a while to get this diagnosed correctly.

…

“The patient was born and raised as a female, but in retrospect realized he did not fully identify with either the male or female gender. In the previous 2 years, he had decided to openly adopt a male gender, name, and manner of dress. He had the intention of pursuing hormone therapy and, eventually, chest reconstruction.”

…

Treatment and afterwards:

“Suicidal thoughts and behaviors were identified as the highest-priority target; after 6 months, these thoughts and behaviors had resolved. The patient was engaged in therapy and did not require significant emphasis on therapy interfering behaviors; therefore, quality-of-life interfering behaviors could be targeted, including purging behaviors, urges to use substances, self-injury, self-care, and interpersonally effective behaviors with friends, family, and other medical professionals. He graduated phase 1 of DBT therapy and proceeded to phase 2 to continue working on healthy emotional experiencing and management of trauma sequelae.

The patient graduated college with a high grade point average and went on to pursue master’s level education. He underwent sex hormone treatment and chest reconstruction.

He developed additional medical comorbidities, including insulin resistance and adrenal insufficiency. These medical conditions necessitated moving back in with his parents, resulting in significant familial conflict. The patient’s therapist made a referral for family therapy through our department, which was coordinated among treatment providers. The patient is enthusiastic about the progress made in treatment and states he often wonders if he would be still be alive without the intervention he received. Over the course of 3 years, his medications were all tapered to discontinuation, with the exception of prazocin 10 mg at bedtime for nightmares, ramelteon 8 mg for sleep, and clonazepam 1 mg three times a day, which was continued to assist with pelvic musculature functioning.”

This is a qualitative study of eating disorders and gender dysphoria. Its strength is that the authors asked transgender people themselves what they thought. Its weakness is that we can’t draw many conclusions from it, although we can use it to find questions for future research.

Limits of the Study

We can’t use it to estimate the prevalence of eating disorders among trans people. The participants were recruited for a study of body image and eating behaviors. Transgender people with eating disorders may be more likely to volunteer for such a study.

We can’t use it to collect statistics on trans people with eating disorders because the data is not uniform. Participants were asked open-ended questions, so we can’t be sure what it means when they give different answers. For example, one person talked about wanting to control his body. Did other participants agree with him and not think to mention it or did they just not care about controlling their bodies?

We can’t look at how individual eating disorders and gender dysphoria developed over time because we don’t have case histories of the participants.

The participants in the study were not formally diagnosed with eating disorders; the data on their eating is self-reported, although convincing. It is not clear from the study how many of the participants currently had symptoms of disordered eating.

On the other hand, we do have some data we can use from this study.

Data from the Study

The authors found 14 people with gender dysphoria who reported current or previous disordered eating and/or excessive exercise.*

About half of the transgender people with an eating disorder talked about gender dysphoria causing their eating disorder and about half did not.**

Other explanations given for the eating disorder included self-control, feeling like an outsider, struggle for autonomy, feeling that one did not deserve to eat, psychological stress and strain, and a belief that being thin would make sexual situations easier.

Explanations related to gender could be classified as efforts to suppress gender or efforts to accentuate gender.

A few participants talked about the relationship between disordered eating and transition. Some saw hormones as positive and some saw them as negative:

Two trans men (born female) said that hormone therapy had helped them to stop caring about their weight.

Two trans women (born male) said that hormone therapy had made them gain weight. (One of the women who said this was waiting for diagnosis and hormone treatment; presumably she was self-medicating.)

One woman who was considering gender reassignment said that breast reduction surgery had helped her stop caring about her weight.***

There was no clear relationship between medical transition and current scores on subscales of the Eating Disorder Inventory-3.**** The three people with the highest total scores included:

Two trans women who had had genital surgery and were on estrogen – the surgery means that their bodies were no longer producing much testosterone; and

One trans men who was taking testosterone and waiting for a mastectomy.

You can read further details of the study below the footnotes.

Future Research

The data we can get from this study isn’t much, but it does point to some important questions for future research. Many of these are questions raised by case studies as well.

What do transgender people see as the main cause of their disordered eating? Do they see it as being about issues like control, autonomy, and stress or do they see it as being related to gender dysphoria? Or both?

Is affirming the desired gender or suppressing biological sex a more important factor in disordered eating? Do trans men and trans women give different answers to this question?

Are there differences between the group of people who see their eating disorder as being related to gender issues and those who do not? Do they have different patterns in terms of when their symptoms of disordered eating developed, what their symptoms looked like, or what happened when they transitioned?

Do people’s perceptions of what causes their disordered eating match reality? Do they have relatives with eating disorders, for example? Were there other factors in their life that might have contributed to the eating disorder? When did the eating disorder develop?

How does the relationship between the eating disorder and gender dysphoria affect recovery from the eating disorder?

When did the disordered eating begin in relation to the gender dysphoria? How did the two conditions develop over time?

Does transition increase or decrease symptoms of disordered eating? Does it have no effect?

Are the effects of transition on eating disorders different for trans men and trans women? In this study, two trans men with eating disorders felt hormone therapy helped their recovery, while two trans women said it made them gain weight.

Trans women and trans men are not getting the same treatment for gender dysphoria; how does that affect eating disorders? In this study, trans men had mastectomies while trans women had genital surgery. Mastectomies might be more important in issues related to body shape. In addition, hormone therapy would have involved completely different medications for trans men and trans women.

Do the hormones themselves play a role in eating disorders, either reducing or increasing symptoms?

Comparison to Case Studies

Prevalence of eating disorders in trans men versus trans women

In this study, slightly over half of the participants were trans men. Trans women were not more likely to have eating disorders than trans men. In contrast, the case studies are overwhelmingly of trans women with eating disorders. What is the real prevalence of eating disorders among transgender people? Is there a difference in the rates among trans men and trans women or not?

It might be that selection bias means that case studies of trans women with eating disorders are written up more frequently. Eating disorders are relatively rare among biological males and potential authors of case studies might notice them more. Conversely, it might be that trans men were more willing to volunteer for the study than trans women or that a group of trans men encouraged each other to participate.

The link between eating disorders and gender dysphoria

Some case studies suggest that factors other than gender dysphoria are central in the development of disordered eating. We have the case of the identical twins who both had anorexia, although only one was transgender. Similarly, the trans man with an eating disorder in this case study had two cousins with eating disorders and this boy’s mother had had anorexia. Then we have the case of the teenage survivor of sexual abuse with PTSD, generalized anxiety disorder, OCD, an eating disorder, and a history of self-harm. The teenager developed gender dysphoria while being treated for her eating disorder; it may be that the trauma was the most important factor in all of her problems.

On the other hand, we have five cases of trans women whose eating disorder began when they decided to live as women, reported in this case study, this one, this one, and this one. In addition, in this case study, one trans woman’s eating disorder seems to have begun at the same time as depression related to her gender.

We also have a couple of case studies where trans men say that their disordered eating was a desire to get rid of feminine features; in this case his curves, breasts, hips, and feminine face and in this case his period and feminine shape. However, in the first case, the trans man also had two cousins with eating disorders.

There is also this somewhat unusual case of an underweight boy with poor eating habits who developed severe anorexia after a doctor suggested that he take testosterone to induce puberty. Again, in this case, his mother had also had anorexia.

Intriguingly in these two cases, gender identity seemed to affect the patient’s symptoms, but not the underlying dissatisfaction with their bodies. In the first case, the patient had a fluid gender identity; when he lived as a man he tried to gain weight and muscle, when he lived as a woman he tried to lose weight. His habits were always pathological and he always hated his body. In the second case, the patient initially identified as a woman. After coming out as gay to supportive friends, he identified as a gay man; as a woman he dieted and as a man he tried to gain muscles.

Of course, since they are case studies, there could be some selection bias. People might be more likely to report cases where gender identity seemed to have affected the eating disorder – or they might be more likely to report cases that are unusual like identical twins and fluid gender identity.

This is where this study is helpful; we see that a number of transgender patients did not bring up gender issues when asked what they thought caused their eating disorders. We also see that some patients thought gender issues were important causes. And now we need another study to find out what that means.

The effect of transition on gender dysphoria

This study found one person considering transition who said that breast reduction surgery had helped her with her disordered eating,

In contrast, there are three individual case studies where sex reassignment surgery contributed to an eating disorder. This trans man began binging and purging for the first time after having his breasts, uterus, and ovaries removed. One of the trans women in this study had an eating disorder in adolescence; her symptoms returned after sex reassignment surgery 20 years later. Finally, this adolescent trans man recovered from an eating disorder and transitioned; after his mastectomy, he began to relapse and ten months later he returned to the clinic for eating disorders.

In the qualitative study two trans men said that hormone therapy had helped them with their eating disorders, while two trans women said hormones had made them gain weight.

On the other hand, two trans women and a trans man who were taking hormones had relatively high scores on three subscales of the Eating Disorder Inventory-3. The two trans women had already had genital surgery (which would have included removing their gonads) while the trans man was waiting for a mastectomy.

Looking at the case studies, there were two trans women with eating disorders who were already on hormones (here and here), although one of them does not seem to have been interested in recovering from her disordered eating. There was one trans woman who believed that transition had cured her, but she was severely underweight, even more so than she had been before transition. In addition, the patients listed above who had problems with their eating after sex reassignment surgery were also on hormones, although it could still be that hormone therapy initially helped them.

On the other hand, there was one trans man whose eating disorder was cured by taking testosterone. In addition, taking puberty blockers helped this adolescent trans woman restore her weight, although, of course, puberty blockers are not the same as hormone therapy for trans women or trans men.

In many of the case studies, patients recovered from disordered eating before they were referred to a gender clinic.

It seems clear that we can not rely on transition to cure an eating disorder and at times it may exacerbate it. Therapy for eating disorders should be aimed at the eating disorder and patients with gender dyshporia and eating disorders should have follow-up care for the eating disorder after they transition.

You can read further details of the qualitative study below the footnotes.

*I count 16 people with an eating disturbance or excessive exercise, according to their Table 2. I’m not sure if this is a typo or if two people reported symptoms that were not considered severe enough to be an eating disorder.

**It is difficult to tell from the study how many people identified gender dysphoria as a cause of their eating disorder. The study talks about 5 people who were suppressing their gender and 3 people who were accentuating their gender, but the two groups overlap. They quote one person twice for both suppressing and expressing their gender. There is no list of which people talked about which possible causes for their gender dysphoria, so there could be more overlap.

Based on the quotes they include, at least seven and possibly eight people mentioned something to do with gender as a possible cause of their eating disorder. This means at least six or seven did not.

It is also possible that some of the people who mentioned gender dysphoria as a possible cause of their eating disorder also mentioned other possible causes. Or that some people did not answer the question.

*** There was also one trans woman (“Julie”) who felt that genital surgery had made her less self-conscious about her body and her weight. However, she had never had any symptoms of an eating disorder or excessive exercise. Her case does not answer the question of how eating disorders may be related to gender dysphoria, especially since there is a group of people with eating disorders and gender dysphoria who did not say that gender issues affected their eating.

****The participants were tested on the Drive for Thinness, Bulimia, and Body Dissatisfaction sub-scales of the Eating Disorder Inventory-3.

More Details on the Study:

Eating Disorders and Gender Dysphoria

The authors found 14 people with gender dysphoria who reported current or previous disordered eating and/or excessive exercise. Looking at their Table 2, I count 16 people with disordered eating and/or excessive exercise, but perhaps there were two cases where the symptoms were not severe enough to be considered disordered.

Of these 14 people, seven or eight mentioned gender as a cause of their eating disorder or excessive exercise (see footnote above as to why the number is unclear). This included 6 or 7 trans men and 2 trans women.

Six or seven people did not mention gender as a cause of their eating disorder or excessive exercise.

Other explanations given included self-control, feeling like an outsider, struggle for autonomy, feeling that one did not deserve to eat, psychological stress and strain, and a belief that being thin would make sexual situations easier.

“I have always wanted to feel that I can control my body.”

“I have felt like I was an outsider since I was little. I have felt inadequate, like I don’t belong to the group, and because of that any criticism about what was most essential to me, my body and how desirable I am, was a really serious thing to me.”

“At that age [eating] was really the only thing I could have an influence on.”

Explanations related to gender fell into three categories –

suppressing gender (“The background of that crazy weight loss was that my curves would disappear”),

accentuating gender (“It is easier to make a man’s body look feminine if you’re a bit thinner”), and

enhanced masculinity (“[After losing a lot of weight] I could buy pants at the men’s department, and they fit in a certain way, the right way, as I see it.”)

Four trans men mentioned suppressing gender, one trans man mentioned accentuating gender, and one trans man mentioned enhancing masculinity. It is possible that there is some overlap between the categories.*

One trans woman mentioned accentuating gender and one trans woman mentioned both accentuating and suppressing gender as possible causes of disordered eating.*

Eating Disorders and Transition

The authors identified sixteen people who had already begun hormone therapy and/or had surgery. In addition, one trans woman seems to have been self-medicating and one trans man had already had breast reduction surgery. Of these 18 people:

Two trans men said that said that taking testosterone had helped them recover from their eating disorder; they stopped caring about weight gain.

Two trans women said that taking hormones caused weight gain and in one case, problems with blood sugar. It is not clear exactly which medications they were talking about – estrogen and blockers or just estrogen. One of the trans women who said this was waiting to begin hormone treatment, so presumably she was self-medicating.

One woman who was considering gender reassignment said that breast reduction surgery had helped her recover from her eating disorder. She no longer cared about weight gain after the surgery.

One trans woman said that after genital surgery she felt comfortable in her body and didn’t care about any fat. However, she had never had any symptoms of disordered eating or excessive exercise, so this may not be relevant to people with eating disorders.

Current Scores on Subscales of the Eating Disorder Inventory-3 (EDI-3)

The study does not separate data on current symptoms of disordered eating and excessive exercise from data on past symptoms. However, the study participants completed three subscales from the Eating Disorder Inventory-E (EDI-3): Drive for Thinness, Bulimia, and Body Dissatisfaction.

We can not use the scores on three subscales of the EDI-3 to diagnose an eating disorder, but they may give some indication of how the participants are doing now.

Of particular concern are “Sue,” “Martha,” and “Leo.” Sue and Martha are trans women who had had genital surgery and were on hormones. Leo is a trans man who was on hormones but was waiting for a mastectomy.

Sue scored 16 on the drive for thinness scale, 17 on the bulimia scale, and 21 on body dissatisfaction. Martha scored 9 on the drive for thinnness scale, 9 on the bulimia scale, and 22 on body dissatisfaction. Leo scored 14 on the drive for thinness scale, 11 on the bulimia scale, and 34 on body dissatisfaction. The three of them had the highest total scores compared to any of the other study participants.

“What frightened me most about the possibility of skin grafts was not my potential appearance, but rather the symbolism—my obviously stitched-together face being interpreted by others as a metaphor for the fakeness of my entire body, my gender. Whenever I shared this thought with cissexual friends, they always responded the same way, telling me that it was nonsense, that cancer-related skin grafts have nothing to do with transsexuality. And while that may be true in a logical sort of way, it seemed to me to be particularly convenient for them to say. Unlike them, I didn’t have the privilege of having my body viewed as inherently natural and congruent. My body is always betraying me, whether it was the male body that used to feel completely alien to me, or my current female state, which others view as inherently unnatural and illegitimate.”